Evidence-Based Mental Healthhttp://hwmaint.ebmh.bmj.com/homepage/EBMH_95x60.gifhttp://ebmh.bmj.com
http://ebmh.bmj.com/cgi/content/short/21/4/e10?rss=1
The systematic assessment of the efficacy and safety of psychiatric medications in children and adolescents started about 20 years ago. Since then, a considerable number of randomised clinical trials have been conducted, including also a series of publicly funded comparative effectiveness studies to evaluate the therapeutic benefit of medications relative to psychosocial interventions, alone or combined with medications. On the whole, these studies have been informative of the paediatric pharmacokinetics, efficacy and safety of the most commonly used psychotropics. As a consequence, a number of meta-analyses have been conducted that have documented both the benefits and harms of the most common medication groups, such as stimulants, antidepressants and antipsychotics. Evidence-based practice guidelines have been produced, and clinicians can now better estimate the therapeutic value and the risk of treatment, at least at the group mean level. However, most clinical trials have been conducted in research settings, and this limits the generalisability of the results. There is a need for evaluating treatment effects under usual practice conditions, through practical trials. The ongoing debate about the proper role of pharmacotherapy in child mental health can be advanced by comparative effectiveness research to assess the benefit/risk ratio of pharmacotherapy vis-à-vis alternative treatment modalities. In addition, analyses of large population databases can better inform on the impact of early treatment on important distal outcomes, such as interpersonal functioning, social and occupational status, quality of life and risk for disability or mortality. Thus far, paediatric psychopharmacology has been mostly the application to children of medications that were serendipitously discovered and developed for adults. By focusing on the neurobiological mechanisms of child psychopathology, it may be possible to identify more precise pharmacological targets and arrive at a truly developmental psychopharmacology.
]]>2018-10-30T03:35:25-07:00info:doi/10.1136/ebmental-2018-300040hwp:master-id:ebmental;ebmental-2018-300040Royal College of Psychiatrists2018-10-27Clinical review214e10e10http://ebmh.bmj.com/cgi/content/short/21/4/125?rss=1

Without continual growth and progress, such words as improvement, achievement, and success have no meaning.—Benjamin Franklin

To celebrate its 20th anniversary, Evidence Based Mental Health has devoted a Special Issue to child and adolescent mental health, acknowledging its crucial role in mental health. The issue, aimed at providing a comprehensive overview of the advances and unmet needs in evidence-based child and adolescent mental health, includes three types of articles.

First, in a series of state-of-the-art reviews, renowned experts in the field provide a critical overview of the major advances in key areas of child and adolescent psychiatry over the past 20 years and highlight future research priorities. In a succinct but very thoughtful review, Doherty et al1 guide us through the journey of the genetics of neurodevelopmental disorders (NDs), with a special focus on its implications for the clinical practice. While initial linkage analysis and candidate gene approaches...]]>

2018-10-30T03:35:24-07:00info:doi/10.1136/ebmental-2018-300066hwp:master-id:ebmental;ebmental-2018-300066Royal College of Psychiatrists2018-10-27Editorials214125126http://ebmh.bmj.com/cgi/content/short/21/4/128?rss=1
This paper attempts to discuss why the early intervention agenda based on the current convention of ‘ultra-high risk’ (UHR) or ‘clinical high risk’ (CHR) for ‘transition’ to psychosis framework has been destined to fall short of generating a measurable and economically feasible public health impact. To summarise: (1) the primary determinant of the ‘transition’ rate is not the predictive value of the UHR/CHR but the degree of the risk-enrichment; (2) even with a significant pre-test risk enrichment, the prognostic accuracy of the assessment tools in help-seeking population is mediocre, failing to meet the bare minimum thresholds; (3) therapeutic interventions arguably prolong the time-to-onset of psychotic symptoms instead of preventing ‘transition’, given that the UHR/CHR and ‘transition’ lie on the same unidimensional scale of positive psychotic symptoms; (4) meta-analytical evidence confirms that specific effective treatment for preventing ‘transition’ (the goal—primary outcome—of the UHR/CHR framework) is not available; (5) the UHR/CHR-‘transition’ is a precarious target for research given the unpredictability driven by the sampling strategies and the natural ebb and flow of psychotic symptoms within and between individuals, leading to false positives; (6) only a negligible portion of those who develop psychosis benefits from UHR/CHR services (see prevention paradox); (7) limited data on the cost-effectiveness of these services exist. Given the pitfalls of the narrow focus of the UHR/CHR framework, a broader prevention strategy embracing pluripotency of early psychopathology seems to serve as a better alternative. Nevertheless, there is a need for economic evaluation of these extended transdiagnostic early intervention programmes.
]]>2018-10-30T03:35:25-07:00info:doi/10.1136/ebmental-2018-300030hwp:master-id:ebmental;ebmental-2018-300030Royal College of Psychiatrists2018-10-27Perspective214128130http://ebmh.bmj.com/cgi/content/short/21/4/131?rss=1
Within the embryonic early psychosis field in the early 1990s, the conceptualisation and definition of an at-risk or ultra-high-risk (UHR) mental state for psychosis was a breakthrough which transformed the clinical and research landscape in psychiatry. Twenty-five years later, we have a new evidence base that has illuminated the neurobiology of the onset phase of psychotic disorder, delivered Cochrane level 1 evidence showing that the onset of full-threshold sustained psychotic disorder can be at least delayed, and is paving the way to a new generation of transdiagnostic research. Here, we document the contribution of the UHR approach to understanding the underlying mechanisms of psychosis onset as well as the long-term outcomes. Particularly, we highlight that psychosis onset can be delayed in those meeting UHR criteria and that these criteria have a higher valence for subsequent psychotic disorders and some valence for persistent non-psychotic syndromes. Critiques have helped to identify some of the limitations of this paradigm, which are acknowledged. These include evidence that psychotic disorders can emerge more acutely and from other, as yet undefined, precursor states. Rather than defending, or alternatively questioning the value of, the UHR approach, we propose a broader, transdiagnostic staging model that is consistent with the pluripotent and variably comorbid trajectories for mental disorders. This approach moves beyond psychosis to capture a wider range of subthreshold symptoms and full-threshold disorders, thus enhancing prediction for the emergence and progression of a range of mental disorders, as well as providing new avenues for early intervention and prevention.
]]>2018-10-30T03:35:25-07:00info:doi/10.1136/ebmental-2018-300061hwp:master-id:ebmental;ebmental-2018-300061Royal College of Psychiatrists2018-10-27Perspective214131133http://ebmh.bmj.com/cgi/content/short/21/4/134?rss=1
Background

The majority of young people receive treatment for depressive symptoms in the UK from staff with minimal specialist mental health/therapeutic training. There is no evidence to guide them as to what treatments are likely to be effective. Interpersonal counselling (IPC) is a reduced form of interpersonal psychotherapy and may be an appropriate treatment to use in this population.

Objectives

To test the effectiveness and acceptability of IPC delivered by youth workers to young people with primarily depressive symptoms.

Methods

Youth workers received a 2-day training course in IPC, followed by regular supervision. They delivered IPC to 23 young people who they would normally see in their service, with depressive symptoms as their main problem. Symptoms were assessed by the Revised Child Depression and Anxiety Scale (RCADS). Qualitative interviews of youth workers and young people assessed acceptability.

Findings

Mean (SD) RCADS depression-T scores fell from 78.2 (11.1) to 52.9 (16.8). All young people and youth workers interviewed were positive about it. Participants detailed specific advantages of IPC above standard counselling, including practical help, the use of goals, psychoeducation and integrating a self-rated questionnaire into treatment.

Conclusions and clinical implications

IPC is likely to be an effective and acceptable treatment for young people with primarily depressive symptoms seen in local authority non-specialist mental health services. Further research is needed to determine if it is more effective than current treatment as usual.

]]>2018-10-30T03:35:25-07:00info:doi/10.1136/ebmental-2018-300028hwp:master-id:ebmental;ebmental-2018-300028Royal College of Psychiatrists2018-10-27Original article214134138http://ebmh.bmj.com/cgi/content/short/21/4/139?rss=1
Background

Survivors of critical illness in childhood commonly display subsequent psychiatric symptoms including emotional and behavioural difficulties, and manifestations of post-traumatic stress disorder (PTSD). Anomalies in inflammatory profiles are an established finding in these childhood psychiatric conditions.

We performed a prospective observational cohort study on 71 children with septic illness, meningoencephalitis and other critical disorders admitted to two PICUs between 2007 and 2010. 3–6 months following discharge, subjects were assessed for global psychiatric risk (ie, presence of emotional and behavioural difficulties on the parental Strengths and Difficulties Questionnaire (SDQ)), and for PTSD risk using the child-rated Impact of Events Scale (IES-8). Inflammatory and related biological markers were transcribed from PICU admission notes (white cell count, lymphocytes, neutrophils, C reactive protein (CRP), platelets, fibrinogen and lactate).

Findings

Global psychiatric risk at follow-up was associated with abnormal lymphocyte count during admission (2=6.757, p=0.014, n=48). In children with sepsis, partial correlation analyses controlling for age and gender highlighted associations between (i) SDQ scores and low lymphocyte count (r=–0.712; p=0.009, n=14), and (ii) IES-8 score and high CRP levels (r=0.823; p=0.006, n=11). These associations remained after correction for multiple comparisons.

Conclusion

These results support the hypothesis that acute inflammation may play a role in determining the development of psychopathology following PICU admission.

Clinical implications

If the findings are replicated, they may help to better highlight which children are at risk of post-PICU psychopathology and appropriately target follow-up.

]]>2018-10-30T03:35:25-07:00info:doi/10.1136/ebmental-2018-300027hwp:master-id:ebmental;ebmental-2018-300027Royal College of Psychiatrists2018-10-27Original article214139144http://ebmh.bmj.com/cgi/content/short/21/4/146?rss=1
Background

Sleep problems are common and impairing in individuals with autism spectrum disorders (ASD). Evidence synthesis including both subjective (ie, measured with questionnaires) and objective (ie, quantified with neurophysiological tools) sleep alterations in youth with ASD is currently lacking.

Objective

We conducted a systematic review and meta-analysis of subjective and objective studies sleep studies in youth with ASD.

Methods

We searched the following electronic databases with no language, date or type of document restriction up to 23 May 2018: PubMed, PsycInfo, Embase+Embase Classic, Ovid Medline and Web of Knowledge. Random-effects models were used. Heterogeneity was assessed with Cochran’s Q and I2 statistics. Publication (small studies) bias was assessed with final plots and the Egger’s test. Study quality was evaluated with the Newcastle Ottawa Scale. Analyses were conducted using Review Manager and Comprehensive Meta-Analysis.

Findings

From a pool of 3359 non-duplicate potentially relevant references, 47 datasets were included in the meta-analyses. Subjective and objective sleep outcome measures were extracted from 37 and 15 studies, respectively. Only five studies were based on comorbidity free, medication-naïve participants. Compared with typically developing controls, youth with ASD significantly differed in 10/14 subjective parameters and in 7/14 objective sleep parameters. The average quality score in the Newcastle-Ottawa Scale was 5.9/9.

Discussion and clinical implications

A number of subjective and, to a less extent, objective sleep alterations might characterise youth with ASD, but future studies should assess the impact of pharmacological treatment and psychiatric comorbidities.

]]>2018-10-30T03:35:25-07:00info:doi/10.1136/ebmental-2018-300037hwp:master-id:ebmental;ebmental-2018-300037Royal College of Psychiatrists2018-10-27Systematic review214146154http://ebmh.bmj.com/cgi/content/short/21/4/155?rss=1
Objective

This is a narrative review of validation and outcome studies using the Weiss Functional Impairment Rating Scale (WFIRS). The objective of the review is to establish a framework for understanding functional impairment and create a definition for functional response and remission.

Methods

We conducted a literature search via MEDLINE, EBSCO and Google Scholar with no date restrictions and reviewed bibliographies of selected publications. Publications found in languages other than English were translated and clarification obtained from the author(s) if needed. Inclusion criteria were any manuscript that was either a WFIRS psychometric validation study or a clinical trial using the WFIRS as an outcome. There were no exclusion criteria.

Results

The WFIRS has been validated in multiple cultures, and in clinical, research and control populations. The WFIRS has robust psychometric properties across ages, psychiatric status and informants. Outcome studies show variable improvement, with different response patterns between domains and among different interventions.

Conclusion

Symptom improvement and remission needs to be complemented with evaluation of functional improvement and remission to obtain a full picture of clinical status over the course of treatment.

]]>2018-10-30T03:35:25-07:00info:doi/10.1136/ebmental-2018-300025hwp:master-id:ebmental;ebmental-2018-300025Royal College of Psychiatrists2018-10-27Systematic review214155164http://ebmh.bmj.com/cgi/content/short/21/4/166?rss=1
What is the evidence that ‘pro re nata’ (PRN) medication is effective for ending agitated outbursts in children and adolescents in psychiatric emergency rooms or inpatient units? Literature search was performed for studies of PRN medication use in children and adolescents that included an outcome measure. One randomised controlled trial, three prospective studies and six retrospective studies that included some outcome measure were identified. Outcome measures were heterogeneous, and frequently did not use standardised metrics assessing agitation level to measure effectiveness. The single small Randomized Controlled Trial (RTC) does not find a difference between placebo and medication, and outcomes of other studies do not control for potential placebo effect of the intervention itself as opposed to the medication. There is insufficient evidence to support the common practice of PRN medications for the management of acute agitation, and no data with which to inform clinical practice, such as which medicines and doses are helpful for specific populations or situations. Psychiatrists have no evidence-based medication interventions for acutely managing agitated outbursts in children and adolescents.
]]>2018-10-30T03:35:25-07:00info:doi/10.1136/ebmental-2018-300039hwp:master-id:ebmental;ebmental-2018-300039Royal College of Psychiatrists2018-10-27Clinical review214166170http://ebmh.bmj.com/cgi/content/short/21/4/171?rss=1
Childhood neurodevelopmental disorders such as attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD) and intellectual disability (ID) typically are complex, heterogeneous, conditions that show considerable clinical overlap.1 There are both genetic and environmental contributions to their aetiology, which are not yet fully elucidated. However, immense progress has been made in our understanding of their genetic basis in the last two decades. This short review aims to synthesise the key findings in this regard, with a focus on some of the factors that are most relevant to clinical practice.

Family and twin studies provided the first evidence of the familial aggregation and heritability of childhood neurodevelopmental disorders. For example, the heritability estimate for ADHD is 88%2 and for ASD it is 64%–91%.3 Families often want to know the likelihood of having a child with a neurodevelopmental problem in future if they themselves or...]]>

2018-10-30T03:35:25-07:00info:doi/10.1136/ebmental-2018-300067hwp:master-id:ebmental;ebmental-2018-300067Royal College of Psychiatrists2018-10-27Clinical review214171172http://ebmh.bmj.com/cgi/content/short/21/4/173?rss=1
In this clinical review we summarise what in our view have been some the most important advances in the past two decades, in terms of diagnostic definition, epidemiology, genetics and environmental causes, neuroimaging/cognition and treatment of attention-deficit/hyperactivity disorder (ADHD), including: (1) the most recent changes to the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases; (2) meta-analytic evidence showing that, after accounting for diagnostic methods, the rates of ADHD are fairly consistent across Western countries; (3) the recent finding of the first genome-wide significant risk loci for ADHD; (4) the paradigm shift in the pathophysiological conceptualisation of ADHD from alterations in individual brain regions to a complex dysfunction in brain networks; (5) evidence supporting the short-term efficacy of ADHD pharmacological treatments, with a different profile of efficacy and tolerability in children/adolescents versus adults; (6) a series of meta-analyses showing that, while non-pharmacological treatment may not be effective to target ADHD core symptoms, some of them effectively address ADHD-related impairments (such as oppositional behaviours for parent training and working memory deficits for cognitive training). We also discuss key priorities for future research in each of these areas of investigation. Overall, while many research questions have been answered, many others need to be addressed. Strengthening multidisciplinary collaborations, relying on large data sets in the spirit of Open Science and supporting research in less advantaged countries will be key to face the challenges ahead.
]]>2018-10-30T03:35:25-07:00info:doi/10.1136/ebmental-2018-300050hwp:master-id:ebmental;ebmental-2018-300050Royal College of Psychiatrists2018-10-27Clinical review214173176http://ebmh.bmj.com/cgi/content/short/21/4/177?rss=1
Bipolar disorder (BPD) is a potentially lifelong condition characterised by extreme changes in mood that may begin in childhood and cause substantial impairment. Over the past decades, BPD has been the focus of increased attention mainly due to controversies surrounding its prevalence, diagnosis and treatment in children and adolescents. This report addresses these controversies by reviewing the extant evidence base, providing clinicians with a summary of the literature on diagnosis, phenomenology and treatment of paediatric BPD. The debate regarding diagnosing children with BPD based on severe irritability and aggression is mostly resolved. The current data support utilising the diagnostic criteria based on episodic changes of mood polarity. Therefore, longitudinal course of illness should be explored in detail when diagnosing BPD. Given high rates of genetic predisposition for BPD, assessment of youth should focus on obtaining accurate family history of this condition. Additionally, there has been a substantial increase in randomised placebo-controlled clinical trials evaluating pharmacological agents for mood stabilisation in children and adolescents, which we summarise in this review. Despite significant progress being made in the field of paediatric BPD, more research is needed in the areas of phenomenology, pathophysiology, course and treatment of this condition in youth.
]]>2018-10-30T03:35:25-07:00info:doi/10.1136/eb-2018-102912hwp:master-id:ebmental;eb-2018-102912Royal College of Psychiatrists2018-10-27Clinical review214177181http://ebmh.bmj.com/cgi/content/short/21/4/182?rss=1
Early intervention is a fundamental principle in health care and the past two decades have seen it belatedly introduced into the field of mental health. This began in psychotic disorders, arguably the least promising place to start. The steady accumulation of scientific evidence for early intervention has eventually overwhelmed the sceptics, transformed thinking in psychotic disorders and created an international wave of service reform. This paradigm shift has paved the way to a more substantial one: early intervention across the full diagnostic spectrum. 75% of mental illnesses emerge before the age of 25 years, and young people bear the major burden for those disorders that threaten the many decades of productive adult life. The paradox is that young people aged between 12 and 25 years have had by far the worst levels of access to mental health care across the whole lifespan. Health services are poorly designed, grossly under-resourced and typically unfriendly to, and untrusted by, young people. Furthermore, until recently there has been a quite striking lack of interest in this transitional age group from clinicians and researchers alike, who had unthinkingly accepted the paediatric–adult split of mainstream medicine without questioning its utility and validity for our field and our young patients. Over the past decade, however, a major shift in momentum has occurred to take early intervention in youth mental health more seriously. Here we discuss the recent advances and evidence supporting an innovative integrated model of youth mental health care and look to the future.
]]>2018-10-30T03:35:25-07:00info:doi/10.1136/ebmental-2018-300060hwp:master-id:ebmental;ebmental-2018-300060Royal College of Psychiatrists2018-10-27Clinical review214182184